Reflections of Dual Diagnosis: A Canadian Perspective

Reflections of Dual Diagnosis:

A Canadian Perspective

By Robert B. Pereira, MD

Published by Agio Publishing House, 151 Howe Street, Victoria BC Canada V8V 4K5

Smashwords Edition

Copyright © 2015, Robert B. Pereira. All rights reserved.

Without limiting the rights under copyright reserved above, no part of this publication may be reproduced, stored in or introduced into a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, photocopying, recording or otherwise), without the prior written permission of both the copyright owner and the publisher of this book.

The author of this book does not advocate the use of any technique as form of treatment for physical or medical problems without the advice of a physician, either directly or indirectly. The intent of the author is only to offer information of a general nature to help you in your quest for physical fitness and good mental and spiritual health. In the event you use any of the information in this book for yourself, which is your right, the author and the publisher assume no responsibility for your actions.

ISBN 978-1-927755-14-3 (hardcover)

ISBN 978-1-927755-15-0 (eBook)

Also by Robert B. Pereira, MD:

Faces of Dual Diagnosis: A Canadian Perspective (Agio Publishing House, 2011 ISBN 978-1-987435-52-6)

Ver. 1a

DEDICATION

To Lucia Maria for her patience, love and support.

Table of Contents

The Crown

Foreword by Joseph Eliezer

Chapter 1: A Note from the Author

Chapter 2: Who Am I?

Chapter 3: Am I?

Chapter 4: I Am

Chapter 5: I Am That

Chapter 6: I Am That I Am

Chapter 7: On Awakening

Chapter 8: On Awareness

Chapter 9: Consciousness Unveiled

Epilogue

Appendix: Bipolar Affective Disorder

About the Author

The Crown

A long time ago, in a distant galaxy,

when laughter roars through the heavens,

a universal being there rests …

Through a Stream …

A lost region, upon the outskirts of foreign lands …

began a dance with a keeper of an eternal flame. In time was born a young son,

and to a chieftain of the noble warrior clans. Though of noblest heritage,

this young man a King of Kings could not yet he become?

By day, came visions of worlds yet to come. Of realities beyond the sands of time

warlords with power did prompt. Yet … "not on bread alone

shall one man live," said he!

Yet, in the true Middle Kingdoms where the birds sing,

where milk and honey forever flow and where the Celestial Realms began

– He at last is led to drink.

By night, in dreams … again and again hidden places deep within

come forth. As dawn approaches the darkness takes leave …

– What has been awakened is bequeathed yet to another’s breath.

– Robert B. Pereira

Foreword by Joseph Eliezer

Imagine interviewing a new doctor to staff the addictions clinic you are running. From the get-go, he discloses his struggles with mental health and addiction. Would you take a chance on a doc like that? We did. And we never regretted it.

I met Dr. Robert Pereira in summer 2009 when I was the clinical director at an addictions clinic in Vancouver, BC. Our medical director had invited Robert to interview for a position. As he shared with us who he was, I was struck by Robert’s candor. Admissions of personal challenges, particularly from medical professionals, as you can imagine, are extremely rare.

As I walked away from that meeting, I had mixed feelings about our decision to hire him. With time, I realized my trepidations were unwarranted. I saw that Robert’s personal struggles gave him the insight into our patients’ struggles that other physicians didn’t possess. His extensive education, keen mind and personal experience uniquely equipped him to help his patients in a way that nobody else could.

I also learned that his openness and honesty weren’t reserved only for the people he wanted to impress. It was his way of being in the world, and it extended to everyone. When he met with patients, his intention was not only to treat but also to connect with them. With Robert, individuals who had been marginalized, abused or disregarded by family or society felt heard, safe and respected.

Dr. Pereira demonstrated uniqueness in other areas as well. Not long into his tenure at the clinic, his high level of enthusiasm for ongoing personal and professional development became apparent. When he learned the clinic had both an infectious disease specialist and a psychiatrist on staff, his immediate response was: How soon can I meet them? Robert knew that having close relationships with other specialists would translate into better care for his patients, and he worked hard to establish and maintain those relationships. Eager to learn from others as if he were a beginner, he approached the field of medicine with the mindset of a Buddha.

As we continued to work together, we realized we had several mutual interests. Writing was one of them. When my first book, Simply Spirit: A Personal Guide to Spiritual Clarity, One Insight at a Time, was released, Robert, with a very full heart, was quick to provide feedback and offer support for my manuscript. He was even more excited to see people’s reactions to it.

When his first book, Faces of Dual Diagnosis: A Canadian Perspective, came out, I was equally excited for him. He’d finally realized his dream of sharing his insights with the world. That book, in my opinion, is a must-read for anyone in the addiction and mental health fields.

The subject of intuition, however, was what fuelled many of our conversations. Both of us recognized intuition as a vital component of mental health. We agreed that using it effectively requires an un-cluttering of the unconscious. When the mind is clearer, intuition is louder. As it puts essential, often unseen, pieces of information together, intuition transforms our experience into a sense of inner knowing. When we follow that sense of inner knowing, we reap better, fuller results in both our personal and professional lives.

As a physician, Robert has seen the profound impact intuition can have in his medical practice. As a psychotherapist, not only do I use intuition as a tool in my practice, but I also help others to clear their minds so they can strengthen their connection to theirs. For this reason, I call my form of therapy Intuition-Enhanced Psychotherapy. And you might as well call Robert’s practice Intuition-Enhanced Medicine.

The passion for the integration of empirical knowledge with intuition-based knowing led Robert to study Eastern philosophies along with Western medicine. This book is a direct result his steadfastness, never-ending curiosity and dedication to the observation of inner and outer patterns of human motivation and behaviour.

As you step into this book, you will be invited into the mind of a very schooled and complex human being, who explores the meaning of Spiritual Medicine and its role in the modern approach to helping people live healthier lives.

May you enjoy the journey.

Joseph Eliezer, MTC, MPCP

Registered Counsellor/Psychotherapist

Author of Simply Spirit: A Personal Guide to Spiritual Clarity, One Insight at a Time

Chapter 1: A Note from the Author

Two souls reside within my breast,

And each one from the other would be parted.

The one holds fast, in sturdy lust for love,

With clutching organs, clinging to the world;

The other strongly rises from the gloom

To lofty fields of ancient heritage.

– J.W. von Goethe in Faust, Part I, Scene II

Anne was both morbidly obese and had osteoarthritis of her knees. Over the time that I knew her – approximately 3 years – she gained a significant amount of weight. When she broke 200 lb. just prior to becoming a patient of mine, she started to complain of severe joint pain in the R knee. Her L knee had been replaced several years prior when she was not a surgical risk. An X-ray showed moderately severe osteoarthritis in the R knee. I wished to start anti-inflammatory medication but could not do so as her kidney function was impaired secondary to chronic kidney disease. I then suggested non-opiate pain relievers. She was agreeable. These worked for a time but eventually the analgesic effects of these medications wore off too due to tachyphlaxis. 

When Anne’s weight broke 250 lb she found the knee pain intolerable. I referred her to an orthopaedic surgeon. I was not expecting she would be told she was an ideal candidate for surgery but did expect that she be told in no uncertain terms that she needed to lose weight before any such surgery could be seriously contemplated. She made a modest effort for a short time to lose some weight but her efforts were hampered by the fact that she was quite sedentary most of the time. At this time I also inquired as to whether she was depressed. I even took the liberty of prescribing her an antidepressant but her weight did not level off and her mood became increasingly labile. 

I inquired about her sleep. She stated that it was nonrestorative for the most part. I arranged for her to have overnight oximetry which turned out to be strongly positive for a diagnosis of obstructive sleep apnea. However, she could not tolerate the CPAP machine. An overnight polysomnogram was ordered and was pending. I was hoping to get medical plan coverage for a machine if the test was strongly positive.

Anne refused to acknowledge that her weight was an issue. She believed that the denial of surgery for her was unwarranted, although she was a definite surgical risk. I told Anne repeatedly that she needed to lose weight if she wanted any kind of surgery. The fact of the matter is that she ate too much and refused to exercise. Her position was that the pain in her knees prevented her from increasing her activity level significantly. This left me in a rather precarious position. 

Eventually I caved in and began prescribing her opiates. I started with weak opiates, in particular Tylenol #3 and then gradually worked up from there. Ultimately, I ended up prescribing methadone to her for her knee pain. Having considered the situation carefully I felt this was the best option for pain control in her case. It worked! The analgesic seemed to also have an antidepressant effect. Unfortunately, I made the mistake of trusting her with the medication. I did not perform pill counts and random urine screens checking for illicit substances. In medical parlance I was opiate naïve at that time. Fortunately, I did not prescribe more than two weeks of analgesic medication at a time but after several months when she requested that I give her the entire allotment at once I reluctantly began doing so. 

Some time later I received a call from the coroner informing me that Anne passed away during sleep. He was looking for more information. I simply stated that Anne likely passed of complications of obstructive sleep apnea. I informed him that she was also diabetic and she had had a high cholesterol level which were now both medicated appropriately and under fairly good control but her weight hovered somewhere around 270 lbs. Anne also suffered from essential hypertension which was controlled.

The shock of Anne’s death prompted me to change the way I prescribe certain categories of medication and the way I practice medicine.

Was Anne clinically depressed? Clearly, Anne was narcotic dependent. I believe that giving her a free hand may have increased her tolerance to the opiate medication considerably. This may have precipitated a mild physiologic withdrawal, which unmasked an underlying depression. However, at this stage this is mere conjecture as she has passed away. 

Her death was a spark needed for me to re-examine how Anne’s health issues were essentially lifestyle based and caused by mental health problems.